a nurse is caring for a client who is receiving an epidural infusion for pain management which assessment finding requires immediate intervention from

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?

A. Redness at the catheter insertion site
B. Report of headache and stiff neck
C. Temperature of 100.1 F (37.8 C)
D. Pain rating of 8 on a scale of 0 to 10

Correct answer: Report of headache and stiff neck

Rationale:

2. You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results?

A. Respiratory acidosis with no compensation
B. Metabolic alkalosis with a compensatory alkalosis
C. Metabolic acidosis with no compensation
D. Metabolic acidosis with a compensatory respiratory alkalosis

Correct answer: Metabolic acidosis with a compensatory respiratory alkalosis

Rationale:

3. Place a washcloth between the skin and tourniquet

A. Provide a bed bath instead of letting the client take a shower
B. Use sterile technique when changing the dressing.
C. Disconnect the intravenous fluid tubing prior to the clients bath.
D. Use a plastic bag to cover the extremity with the device

Correct answer: Use a plastic bag to cover the extremity with the device

Rationale:

4. What is the most abundant positive ion in blood plasma?

A. Potassium.
B. Calcium.
C. Sodium.
D. Both potassium and sodium are in equal concentrations.

Correct answer: C

Rationale: The correct answer is C: Sodium. Sodium (Na+) is the most abundant cation in the extracellular fluid, including blood plasma. It plays a crucial role in maintaining fluid balance, nerve function, and is essential for various physiological processes. Choice A, Potassium, is also an important ion in the body but is predominantly found intracellularly. Choice B, Calcium, is an essential mineral in the body but is not the most abundant positive ion in blood plasma. Choice D is incorrect as sodium is the primary positive ion in blood plasma, with a much higher concentration compared to potassium.

5. A patient is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this patient, the nurse's priority would be to assess her:

A. Neuromuscular function
B. Bowel sounds
C. Respiratory rate
D. Electrocardiogram (ECG) results

Correct answer: D

Rationale: In a patient with a serum potassium level of 6 mEq/L due to spironolactone use, the nurse's priority is to assess the Electrocardiogram (ECG) results. Hyperkalemia can lead to life-threatening arrhythmias, such as ventricular fibrillation, which can be detected on an ECG. While changes in neuromuscular function, bowel sounds, and respiratory rate can occur with hyperkalemia, the most critical assessment related to the patient's condition would be monitoring the ECG for signs of cardiac complications.